Situation:
On the 7/7, an 80 yr old man was bought in by ambulance to ED from a high-level care nursing home complaining of an increased productive cough, thick green sputum, shortness of breath and lethargy. He was diagnosed with an acute exacerbation of COPD. This patient is well known by the hospital with his previous admission with the same diagnosis and heart failure leading him to be placed on continuous home O2 therapy. This patient stated that he is very anxious all the time but especially about mobilising, as he was unable to move prior to admission because of his shortness of breath and lethargy. He has not attempted ambulating let alone sitting out of bed since admission and refuses to mobilise with anyone except the physios. He is prone to pressure sores and has only recently recovered from a sacral pressure wound one week ago. When visiting this patient, he was very anxious about mobilising for the first time but very keen to ambulate with us Physios as he had been told by the doctors that he will be sent back to the nursing home the following day. Normally this patient ambulates with a 4-wheeled walker on 2LO2 for around 20m before getting short of breath but can continue up to 100m.
Task:
It was my task to perform the necessary assessments to get this patient up and possibly ambulating for the first time since admission.
Action:
After speaking with the patient’s nurse who encouraged ambulation, I had a check of the patient’s observation chart, which revealed that his blood pressure was 90/55 and his SpO2 was 94%on 4LO2. The nurse had just taken these obs before I entered the room so I was happy that they were up-to-date. After a thorough subjective and the patient had no complaints, I proceeded treatment with the ACBT deep breathing exercise and was able to produce 3 Tbsp of thick purulent sputum and increase his SpO2 to 96%. My next plan for his treatment was to get the patient sitting on the edge of the bed, standing up and then ambulating with his 4-wheeled walker.
The patient was able to independently mobilise himself into sitting on the edge of the bed. Here he complained of dizziness. I had the obs monitor setup already anticipating a drop in blood pressure as the patient has a history of postural hypotension. I re-took his BP which had dropped to 85/40. His BP remained at this level even with encouraging the patient to foot pump and deep breathe and the patient denied further dizziness but even more anxious now to ambulate. We returned the patient back to bed supine and reported this outcome to his nurse.
Results:
As a result from the patient’s drop in BP, I was unable to complete my set treatment for him. Although with my evaluation of the situation at hand, I believe it was better to not take the risk of ambulating this patient especially with his anxious presentation. Discussions with the patient himself and my supervisor, we came to the agreement to follow him up later in the afternoon or the following day before discharge.
Evaluation:
I think I took the correct precautions in this situation and decided not to risk a fall or collapse of my patient. I think I handled the situation very well especially with my attention to the fact that I read in the patient’s past medical history that he has postural hypotension. Although this may not have been too severe, I was pleased with my actions and we didn’t increase the patient’s anxiety with getting him to complete a task which may have ended badly. I appreciate the need to take a patient’s BP with a change in positions now whereas before I never actually saw any significant change in BPs. I probably could have continued treatment in bed though but we did follow up the patient later that afternoon where his obs were stable and we continued mobilisation safely.
Strategies:
Always take your own obs!
Make note of hypotension or hypertension in the patient’s past medical history so you aren’t surprised with the ob charts or if their BP suddenly drops
Always ask a patient how they’re feeling with positional changes
Anxious patients need lots of encouragement and positive feedback.
Always be safe rather than sorry!
On the 7/7, an 80 yr old man was bought in by ambulance to ED from a high-level care nursing home complaining of an increased productive cough, thick green sputum, shortness of breath and lethargy. He was diagnosed with an acute exacerbation of COPD. This patient is well known by the hospital with his previous admission with the same diagnosis and heart failure leading him to be placed on continuous home O2 therapy. This patient stated that he is very anxious all the time but especially about mobilising, as he was unable to move prior to admission because of his shortness of breath and lethargy. He has not attempted ambulating let alone sitting out of bed since admission and refuses to mobilise with anyone except the physios. He is prone to pressure sores and has only recently recovered from a sacral pressure wound one week ago. When visiting this patient, he was very anxious about mobilising for the first time but very keen to ambulate with us Physios as he had been told by the doctors that he will be sent back to the nursing home the following day. Normally this patient ambulates with a 4-wheeled walker on 2LO2 for around 20m before getting short of breath but can continue up to 100m.
Task:
It was my task to perform the necessary assessments to get this patient up and possibly ambulating for the first time since admission.
Action:
After speaking with the patient’s nurse who encouraged ambulation, I had a check of the patient’s observation chart, which revealed that his blood pressure was 90/55 and his SpO2 was 94%on 4LO2. The nurse had just taken these obs before I entered the room so I was happy that they were up-to-date. After a thorough subjective and the patient had no complaints, I proceeded treatment with the ACBT deep breathing exercise and was able to produce 3 Tbsp of thick purulent sputum and increase his SpO2 to 96%. My next plan for his treatment was to get the patient sitting on the edge of the bed, standing up and then ambulating with his 4-wheeled walker.
The patient was able to independently mobilise himself into sitting on the edge of the bed. Here he complained of dizziness. I had the obs monitor setup already anticipating a drop in blood pressure as the patient has a history of postural hypotension. I re-took his BP which had dropped to 85/40. His BP remained at this level even with encouraging the patient to foot pump and deep breathe and the patient denied further dizziness but even more anxious now to ambulate. We returned the patient back to bed supine and reported this outcome to his nurse.
Results:
As a result from the patient’s drop in BP, I was unable to complete my set treatment for him. Although with my evaluation of the situation at hand, I believe it was better to not take the risk of ambulating this patient especially with his anxious presentation. Discussions with the patient himself and my supervisor, we came to the agreement to follow him up later in the afternoon or the following day before discharge.
Evaluation:
I think I took the correct precautions in this situation and decided not to risk a fall or collapse of my patient. I think I handled the situation very well especially with my attention to the fact that I read in the patient’s past medical history that he has postural hypotension. Although this may not have been too severe, I was pleased with my actions and we didn’t increase the patient’s anxiety with getting him to complete a task which may have ended badly. I appreciate the need to take a patient’s BP with a change in positions now whereas before I never actually saw any significant change in BPs. I probably could have continued treatment in bed though but we did follow up the patient later that afternoon where his obs were stable and we continued mobilisation safely.
Strategies:
Always take your own obs!
Make note of hypotension or hypertension in the patient’s past medical history so you aren’t surprised with the ob charts or if their BP suddenly drops
Always ask a patient how they’re feeling with positional changes
Anxious patients need lots of encouragement and positive feedback.
Always be safe rather than sorry!
No comments:
Post a Comment